20] Allen and Johnston believe that 1) optimal closure of a scalp flap requires two layers, 2) that flaps must not be closed under tension, so as to avoid ischemia at the suture line, and 3) that the closure of the galea aponeurotica should be separated from a second suture line through dermis [21] They suggest that minimizing scalp flap necrosis depends on 1) careful handling of the flap intraoperatively (excess manipulation or prolonged angulation after reflection can cause ischemia), 2) not using Raney clips (to avoid skin-edge ischemia), 3) assuring a good vascular supply by closing the wound with minimal tension (with the use of relaxing incisions and flap undercutting if necessary), and 4) avoiding tight dressings postoperatively.

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